NUR 211 Test #3
Nursing Interventions for Anaphylaxis
Airway Stay with client Call HCP and rapid response Stop IV meds Start IV fluids- helps prevent hypotension Administer O2 Check VS Elevate HOB Ensure intubation and trach equipment ready Prepare to administer epi and diphenhydramine Document
The nurse performed physical assessments for four female clients during their general checkup. Which client is most at risk of developing breast cancer? -Client A- 60 y/o, Family Hx- Yes, 2 Kids, Menopause at 45 y/o -Client B- 60 y/o, Family Hx- Yes, No kids, Menopause at 50
Client B
A patient with systemic lupus erythematosus (SLE) may experience which symptoms related to Raynaud' s phenomenon?
Cyanosis of fingers
The nurse is performing a skin assessment of a client. Which findings may indicate a risk of skin cancer?
Lesion Lumps Rashes
Which side effects would the nurse teach the patient with human immunodeficiency virus (HIV) to monitor when receiving antiretroviral therapy (ART) for a long time?
Lipodystrophy
Stage II
Spread to nearby tissue
Which type of immune response is an autoimmune disorder?
Hypersensitivity
Stages 0
In situ
Leukemia Clinical Manifestations
-Abnormal WBCs continue to accumulate -Splenomegaly -Hepatomegaly -Life threatening complication in which the blood thickens and blocks circulatory pathways -Lymphadenopathy (swelling of lymph nodes) -Bone pain -Meningeal irritation -Oral lesions -Chloromas (tumor) -Bleeding -Fever -Weight loss -Swelling -Anorexia -Fatigue -Decreased number and function of WBC- increased risk for infection
Breast Cancer Risk Factors
-Age greater than 60 -Family Hx -Early menarche and late menopause -Nulliparity -Obesity -Recent hormone replacement -High dose radiation exposure to chest -Smoking -Alcohol intake -Environmental
Breast Cancer Nursing Interventions
-Instruct client on BSE -Look for tiny bumps or lumps, particularly along the incisional tract -Their skin should be examined up the clavicle, and down to three inches above the waist (breast tissue there)
SLE Patient Education
-Provide emotional support, encourage client to verbalize feelings, provide information to support groups and community resources -Avoid exposure to sunlight and ultraviolet light. Wear sunscreen and wear a hat in the sun. -Do not take live vaccines while on steroids -Provide a high protein and high iron diet. -Make sure to conserve energy, pace activities and balance rest with exercise. -Stay away from sick people while on steroids, due to low immune system. -Drink 8 glasses of water a day -Pregnancy can cause exacerbation of lupus flare up. -Avoid physical and emotional stress. to decrease the risk of exacerbations. -Use mild soap -Avoid drying soaps, powders and household chemicals. -Monitor weight, intake and output daily.
Sickle Cell Anemia Nursing Interventions and Tx
-Relieve pain -IV hydration -Oxygenation -Prevent/Tx Infection promptly -DVT prophylaxis -Folic acid supplements help with the production of new red blood cells -Cluster care -Deep breathing exercises/ spirometry -Continuous and breakthrough analgesia- morphine and hydromorphone -Hematopoietic stem cell transplantation is the only available cure -Hydroxyurea is the only anti-sickling agent shown to be beneficial- make RBCs bigger -Blood transfusion, iron supplementation but you can overdose on iron
SLE Clinical Manifestations
-SLE affects multiple systems in the body -Erythema of the face- malar rash (butterfly rash) -Dry, scaly, raised discoid rash on the face or upper body- scarring in older lesions -Painless oral ulcers -Fever -Weakness, malaise, and fatigue -Anorexia -Alopecia -Weight loss -Photosensitivity -Joint pain -Erythema of the palms -Anemia -Positive antinuclear antibody (ANA) test and lupus erythematosus preparation -Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level
Hemophilia Clinical Manifestations
-Slow persistent prolonged bleeding after minor injuries, traumas, and small cuts -Delayed bleeding after minor injuries- several hours or days delayed -Uncontrollable hemorrhage after dental extractions or irritation gingiva -Nosebleeds -GI bleeding -Hematuria -Splenic rupture from falls -Bruising and subcutaneous hematomas -Possible compartment syndrome -Hemarthrosis
The nurse teaches the parent of a child with classic hemophilia how to administer plasma component factor VIII prescribed three times a week. Which instruction would the nurse give the parent about administration time?
Give in the morning on scheduled days
Which intervention would the nurse include in the plan of care for a client with breast cancer who received doxorubicin and cyclophosphamide 12 days ago and now has a white blood cell (WBC) count of 1.4 cells/mm and reports shortness of breath and activity intolerance?
Institute neutropenic precautions.
Which information will the nurse emphasize when teaching skin care to a client scheduled to receive irradiation to the chest wall after a tumor was removed from the lung?
Keeping the skin dry to protect it from excoriation
The nurse is caring for a client during the early postoperative period after a modified radical mastectomy. Which instruction would the nurse provide to limit edema in the affected arm?
"Use pillows to elevate the affected arm above the level of the heart."
HIV/AIDS Patient Education
*Important to adhere to drug regimen* -Safe sex practices (using condoms, practicing abstinence) -Avoid exposure to other STIs, blood-borne disorders, and sick people -Eat plenty fruits/veggies and increase protein (protein-helps with muscle wasting) -How to cope with diagnosis, symptoms, and treatments of HIV -Maintain and develop healthy and supportive relationships -Maintain activities and productivity -Viral load is high at beginning of HIV diagnosis -Talk to provider about live vaccines
Leukemia Nursing Interventions
-Admin chemo as prescribed -Monitor for signs of infection -Strict aseptic technique -Protect from injury -Admin antimicrobials, stool softeners as prescribed -Monitor temp closely -Fatigue and nutrition -Bleeding precautions -No rectal temp or needle sticks -May need PLT or PRBC transfusions -Assess for internal hemorrhage -Education client to use soft tooth brushes -Well balanced diet and small frequent feedings
RA Extrarticular Clinical Manifestations
-High levels of biomarkers -Low-grade fever, fatigue, & weakness -Anorexia, weight loss, & anemia -Rheumatoid nodules- Under skin, Nontender masses, Found on bony areas exposed to pressure -Nodular myositis- Pleurisy, pleural effusion, pericarditis, pericardial effusion, cardiomyopathy -Scleral nodules- Cataracts/vision loss -Sjogren's Syndrome- Damage to lacrimal (tear producing) glands, Dry gritting feeling in eyes/mouth -Felty Syndrome- Enlarged spleen and low WBC, Increased risk for infection & lymphoma -Depression -Raynaud's Phenomenon- blood vessels in extremities narrow, restricting blood flow, white finger tips
RA Patient Education
-Identify & correct safety hazards in the home -Instruct correct use of assistive/adaptive devices -Energy conservation measures (nap) -Review prescribed exercise program and using comfort measures prior to (heat/cold) -Sit in chair with a high, straight back -Use only a small pillow when lying down -Protect joints by avoiding repetitive motions -Stress importance of follow-up visits with PCP -Instruct importance of med compliance
RA Nursing Interventions- Fatigue
-Identify factors that contribute to fatigue -Monitor for signs of anemia- Administer iron, folic acid, and vitamins as prescribed -Monitor for medication-related blood loss- Stool occult blood test -Instruct client in strategies to conserve energy- Pacing activities/using assistance when possible, Nap when connected
RA Intrarticular Clinical Manifestations
-Inflammation, tenderness, warmth & stiffness of the joints- Symmetrically effected, Swelling may be noted -Fingers may become spindled shaped -Moderate to severe pain with morning stiffness lasting longer than 30 minutes-60 minutes-several hours -Joint deformities & decreased ROM -Muscle atrophy -Subluxations -Spongy, soft feeling in the joints -Elevated ESR & positive RF -Radiographic study showing joint deterioration -Synovial tissue biopsy revealing inflammation
Lung Cancer: Lobectomy/VATS
-Lobectomy: Entire lobe of lung removed, Treatment for early stage NSCLC -VATS: Video associated thoracic surgery also used for early stage NSCLC, Less invasive, less recovery, and less risk for infection, A small tube called a thoracoscope is inserted through a small cut between the ribs. Used for tumors located outside the lung. -Preop Interventions: Prepare client for the surgical procedure -Post-op Interventions: Maintain airway, assess respirations and cardiac status, maintain chest tube drainage system, administer O2 as prescribed, encourage ROM exercises as prescribed, encourage deep breathing and coughing -Assess client and family understanding of dx tests, dx, tx options, and prognosis
Breast Cancer Post-op Mastectomy
-Provide incisional care with lanolin as prescribed -There should be a sign above the bed indicating "No IVs, No injections, and No BP's in the affected arm" -Place patient in semi-fowlers position. You should turn from the back to the non-operative side. Affected arm elevated above level of heart. -ROM in affected arm and you can also use a compression sleeve for swelling. Take the compression sleeve off periodically to check skin integrity. -If there is a drain, maintain suction
Methotrexate
-Slows degenerative effects of RA -Secondary to NSAIDs -First choice for severe RA cases -Interventions: ▪Educate on signs of infection ▪When to report symptoms to PCP ▪Monitor injection site ▪Pain, swelling, inflammation ▪Consult with PCP before receiving live vaccines ▪Labs for neutrophils, WBC, liver function & platelets prior to treatment
Which nursing concern is a priority when a 6-year-old child with sickle cell disease is admitted with a vasoocclusive crisis (pain episode)?
Hydration Pain management Oxygen supplementation
Which assessment findings may be associated with rheumatoid arthritis (RA)?
Joint stiffness Dry, itchy eyes Rheumatoid nodules Mouth infection and dental caries High white blood cell (WBC) count
The nurse is assessing an adolescent child with the diagnosis of hemophilia. In which part of the body would the nurse expect bleeding to occur?
Joints
Which common concern of most parents of children with sickle cell anemia would the nurse address at a family education conference?
Sharing feelings regarding the transmission of the disorder
n which area does melanoma most commonly occur?
Site where moles are evident *These pigmented cancers may arise in melanin producing epidermal cells. Melanoma most commonly occurs at the place where moles or birthmarks are evident*
Which assessment finding indicates a complication in a client who had a lobectomy and has a chest tube attached to suction?
Subcutaneous emphysema on the second postoperative day *Subcutaneous emphysema on the second postoperative day should not occur; it is evidence of a leak from the chest tube or the lung into the subcutaneous tissue*
Which value for hemoglobin would the nurse expect in a client who is experiencing sickle cell crisis?
6 to 8 g/100 mL (60-80 mmol/L)
Skin Cancer ABCDE
A- Asymmetry B- Border C- Color D- Diameter E- Evolving
Which preventive measures would the nurse teach the patient who recently developed a latex allergy?
After removing gloves, wash hands with mild soap and dry thoroughly. Always wear a Medic Alert bracelet and carry an injectable epinephrine (EpiPen) pen. Use nonlatex gloves for activities that do not involve contact with infectious material.
Which factor may cause an exacerbation of systemic lupus erythematosus?
Becoming fatigued
Which patient statements reflect understanding of the educational content presented by the nurse for patients who are newly diagnosed with human immunodeficiency virus (HIV)?
"I need to keep my appointments for follow-up laboratory work." "I will call my health care provider if I am too sick to take these drugs." "I won't take any new drugs or herbal products without checking with my health care provider first."
Which statement by the client indicates the need for further learning about skin cancer prevention?
"I should limit sun exposure to between 7 AM and 12 PM."
Which client statement indicates that the nurse's preoperative teaching about right upper lobectomy has been effective?
"I will have chest tubes to help with drainage after surgery."
Which statement by a client with metastatic melanoma who is being treated with interferon gamma 1b indicates that teaching was understood?
"I will increase my fluid intake to several liters (quarts) every day." *Increasing fluid intake to several liters (quarts) every day helps flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment*
Breast Cancer Clinical Manifestations
-Lump detected in upper outer quadrant of breast -Mammographic abnormality -Presence of nipple discharge -Painful breasts -Breast asymmetry
Breast Cancer Procedures
-Lumpectomy: most common, conservation surgery, completed in patients with tumors smaller than 4-5 cm -Radiation/ Chemotherapy -Axillary node dissection -Modified radical mastectomy: removal of breast and axillary lymph nodes, preserves pectoralis major muscle
Etanercept
-Made from living organism -Same as DMARDS effect -Interventions: ▪Injection site reactions are common ▪Monitor injection site ▪Pain, swelling, inflammation ▪Risk for HF ▪Associated with ▪CNS demyelination disorders ▪Hematological disorders ▪Consult PCP before live vaccines/may need TB skin test
Hypersensitivity Pharm
Epi- vasoconstrictor, relaxes bronchial muscles, IM q5-15mins Diphenhydramine- IV, helps w/ rash and itching, drowsiness Albuterol- bronchodilator Cromolyn- cell stabilizing Montelukast- helps with bronchospasm Corticosteroids- IM methylprednisone, prevention of biphasic symptoms, helps relieve allergic rhinitis
A 12-year-old child with sickle cell anemia is admitted during a vasoocclusive crisis. Which is the priority of care for this child?
Relieving pain
Lung Cancer Late Manifestations
-Anorexia -Fatigue -N/V -Dysphagia -Hoarseness -Unilateral paralysis of diaphragm -Superior vena cava obstruction -Palpable lymph nodes
RA Nursing Interventions- Self Care
-Assess need for assistive devices -Raised toilet seats/self-rising chairs/wheelchairs/scooters -Work with OT or PCP to obtain assistive or adaptive devices -Instruct client on alternative strategies for ADLs
RA Pharm
-Treatment goal- Early detection, Aggressive treatment to preserve joint function -NSAIDs -ASA -Glucocorticoids -Disease-modifying Antirheumatic Drugs (DMARDs)-Methotrexate, Sulfasalazine, Azathioprine -Biologic DMARDS- Etanercept
RA Labs
-WBC will be elevated in synovial fluid (WBC 4.5-11) -CRP will be increased (CRP 3 mg/L) -Rheumatoid Factor is a protein produced by your immune system that can attack healthy tissue in your body (will be present in RA, 0-20)
RA Dx Procedures
-Positive Rheumatoid Factor -Increased ESR and CRP -Synovial fluid analysis- Slightly cloudy/Straw colored/Fibrin flecks, WBC increased -X-rays- With other testing, not used alone to diagnose RA, Soft tissue swelling/possible bone degeneration, Based line can be used with treatment
Hemophilia Education
-Apply pressure for superficial bleeding for 15 mins -Signs of internal/intracranial bleeding: pain at injury site, swollen or tight abdomen, extreme thirst, N/V, breathlessness -Elevate and ice affected joints -Monitor for hematuria -Avoid contact sports -Use protective devices with activities -Avoid aspirin and ibuprofen as they can worsen bleeding -Practice good dental hygiene
Which instruction would the nurse give to a client who will be scheduling a mammogram?
"Each breast will be firmly compressed between 2 plates."
The parent of a toddler with hemophilia A asks the nurse, "Can I give my child ibuprofen for fever or pain?" How will the nurse respond?
"Give your child acetaminophen. Ibuprofen may cause bleeding."
Sickle Cell Anemia Risk Factors
-African American -Males -Sickle call carriers are both parents
How is HIV transmitted?
Blood Semen Vaginal secretions Breast milk
Stage 1
Localized
Hypersensitivity Skin Test Nursing Interventions
Never leave patient alone Precaution in anaphylaxis No recommended for patient with food allergies
Synvectomy
Removal of synovia Maintains joint function
Arthroplasty
Replacement of diseased joints with artificial joint Restore motion to joint and function of muscles, ligaments, and other soft tissue structures
HIV Clinical Manifestations
-Malaise, fever, anorexia, weight loss, influenza-like symptoms -2-4 weeks after newly infected -Lymphadenopathy for at least 3 months -Leukopenia -Diarrhea -Electrolyte issues -Fatigue -Night sweats -General condition of the skin -Activity tolerance -Neurological status -Nutrition and food intake -Presence of opportunistic infections -Protozoan infections -Pneumocystis jiroveci pneumonia -Neoplasms -Kaposi's sarcoma, manifested as purplish-red lesions of internal organs and skin -B-cell non-Hodgkin's lymphoma -Cervical cancer -Fungal infections -Candidiasis, histoplasmosis
Sickle Cell Anemia Clinical Manifestations
-Pain from tissue hypoxia and damage -Pallor of mucus membranes -Jaundice from hemolysis
Lung Cancer Early Manifestations
-Persistent cough with sputum -Hemoptysis -Dyspnea -Wheezing -Pneumonitis -Chest pain
Breast Cancer Tx
-Plan determined by prognosis factors, clinical stage, and biology of cancer -Surgical interventions -Radiation therapy -Chemotherapy -Hormonal therapy -Biological therapy
RA Nursing Interventions- Physical Mobility
-Preserve joint function -Provide ROM exercises -Balance rest and activity -Splints may be used during acute inflammation -Prevent flexion contractures -Apply heat or cold as prescribed- Apply modality prior to exercise; ie. ice or warm bath -Apply paraffin baths and massage as prescribed -Encourage consistency with exercise program -Use joint protecting devices -Avoid weight bearing on inflamed joints- Repetitive movements using the same muscles/joints
New Cancer Dx Spread Nursing Interventions
-Providing emotional support -Managing Acute Pain -Improving Nutritional and FV status -Minimizing infection risk -Following Med Reg Surgical Removal
Pain Syndrome After a Mastectomy
-S/S: Chest and upper arm pain, tingling down arm, unbearable itching -Tx: Non-steroidal anti-inflammatory drugs, Antidepressants, Topical lidocaine patches, and Anti-seizure drugs
SLE Dx Procedures
A person is classified as having SLE if 4 or more of the criteria are present, serially or simultaneously, during any interval of observation: -Neurologic disorder: seizures or psychosis In the absence of causative drugs or known metabolic disorders -Nonerosive arthritis: 2 or more peripheral joints with tenderness, swelling, effusion (polyarthralgia) -Discoid rash: raised patches with scaling follicular plugging; scarring in older lesions -Malar rash: fixed erythema, flat or raised (butterfly rash) -Photosensitivity: Skin rash as unusual reaction to light- can cause butterfly/ malar rash -Renal Disorder: Persistent proteinuria or cellular casts in urine -Oral ulcers: usually painless -Immunologic disorder: anti-DNA antibody or antibody to Sm (Smith) nuclear antigen or positive antiphospholipid antibodies -Hematologic disorder: hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia -Antinuclear antibody (ANA): abnormal titer
A patient with pruritus and a rash over the trunk and arms develops audible wheezes and difficulty breathing. Per the facility's protocol, which action would the nurse implement?
Administer epinephrine (Adrenaline)
An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. Which pathophysiology is correct?
Blockage of small blood vessels as a result of clumping of RBCs
Which educational content would the nurse discuss with the patient about metabolic side effects when taking antiretroviral therapy (ART) for eight months?
Body changes include central fat accumulation and peripheral wasting. Elevated triglyceride levels and decreases in high-density lipoproteins can occur. Exercise, dietary changes, and calcium and vitamin D supplements for bone health.
Arthrodesis
Bony fusion of a joint Regain some mobility
Which information would the nurse include in his or her teaching for a class on breast health?
Breast awareness will help a client know if there are changes in her breasts.
Which physical assessment finding would the nurse expect in a client admitted with a suspected malignant melanoma on the arm?
Brown or black mole with red, white, or blue areas
Which assessment finding is a classic feature of systemic lupus erythematosus?
Butterfly rash
Which action would the nurse take first when an excessive amount of serosanguinous drainage is noted on the mastectomy dressing of a client who has just had a mastectomy and has a portable wound drainage system to the axillary area in place?
Checking the function of the drainage system
A child with leukemia is to continue taking prednisone at home. The nurse discovers that the child's sibling is home from school with chickenpox. Which is the nurse's priority concern?
Chickenpox can be fatal to individuals with leukemia.
Which nursing intervention would the nurse implement for client safety and quality of care when placing a short peripheral venous catheter?
Choose a distal site. Do not use the arm on the side of a mastectomy. Choose a vein of appropriate length and width to fit the catheter's size.
RA
Chronic autoimmune disorder Inflamed connective tissue- synovial joints
Which prescribed treatment would the nurse question when a client who has sickle cell anemia has been admitted with acute chest syndrome?
Daily iron supplement
Which finding in a client who has just returned to the nursing unit after having right upper lobectomy requires rapid action by the nurse?
Deviation of the client's trachea to the left side *Deviation of the trachea indicates increased intrathoracic pressure on the right, causing compression of the heart, aorta, and superior and inferior vena cava and leading to decreased cardiac output*
Which instructions will the nurse include when educating a patient with rheumatoid arthritis (RA) about small joint protection?
Do not knit or sew for long periods.
After administering a few milliliters of contrast media to a patient undergoing a cerebral CT scan with contrast, the health care provider assesses the patient and immediately stops the infusion. Which clinical manifestations would lead the health care provider to discontinue the contrast dye?
Dyspnea Hypotension Rapid, weak pulse
Which clinical manifestation would the nurse expect to find in a client with a new diagnosis of acute lymphocytic leukemia (ALL)?
Ecchymosis
RA Risk Factors
Equal across ethnic groups Age 30-50 Women Genetic predisposition-HLA gene Smoking with genetic predisposition RA developed after stressful event
Which risk factor would the nurse discuss with a local women's group as indicating the need for breast cancer screening at an earlier age?
Family history of breast cancer
An antimalarial agent may be prescribed for a patient with systemic lupus erythematosus (SLE) to treat which conditions?
Fatigue Moderate skin and joints disease
Which prescribed cytokine medication would the nurse administer to treat chemotherapy-induced neutropenia?
Filgrastim
A patient develops severe respiratory distress and hypotension within a few minutes after receiving a newly prescribed IV medication. Which actions does the nurse take?
Maintain IV access. Administer high-flow O via face mask. Administer 0.3 to 0.5 mg epinephrine.
Stage IV
Metastatic Spread
Which skin growth would require health care provider follow-up to evaluate for possible skin cancer?
Mole that is 12 mm wide
A patient is experiencing rheumatoid arthritis (RA) with decreased function of the joint. If the problem is not corrected, which complication can occur?
Permanent loss of function
A 28-year-old woman is diagnosed as having cancer of the left breast. A simple mastectomy is performed. Which action would be included in the plan of care immediately after surgery?
Placing the client in the semi-Fowler position with the left arm elevated *The semi-Fowler position and elevation of the arm on the affected side minimize edema related to the inflammatory process*
When providing care to a child with leukemia, the nurse notes blood on the pillowcase and several bloody tissues. Which blood component value on the child's laboratory results would the nurse verify?
Platelets
What would the nurse include in the plan of care to minimize the potential for a sickling episode in a child with sickle cell anemia?
Promoting adequate oxygenation
HIV Dx Procedures
Rapid HIV antibody testing -If risky behavior retest in 4-6 weeks -Educate on PrEP
The primary health care provider of a woman who had a mastectomy has arranged for a mastectomy peer support visit. What is the purpose of the referral?
To prevent social isolation
The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection?
To the client from outside sources
Which clinical signs of hydration would the nurse assess in a toddler experiencing a sickle cell crisis?
Turgor of tissue Texture of mucous membranes
A toddler with hemophilia is admitted for observation after a motor vehicle collision. The toddler has several bruises but no other apparent injuries. Which complication would the nurse monitor the toddler for?
Undetected injury
What breathing patterns may a patient with anaphylaxis have?
Wheezing Stridor
Which instructions will the nurse include when teaching a group of caregivers about the home care of a patient with rheumatoid arthritis (RA)?
Never place pillows below the knees. Perform aquatic exercise in warm water. Use lifts and elevators instead of the stairs.
Which order would the nurse implement first for a patient showing signs of anaphylactic shock from an insect sting?
Epinephrine 1:1000, 0.5 mg IM
RA Nursing Interventions- Disturbed Body Image
-Assess client's reaction to body changes -Encourage client to vocalize feelings -Assist the client with self-care activities/grooming -Encourage the client to get dressed daily- Street clothes depending on facility
Sickle Cell Anemia Education
-Avoid high altitudes -Maintain adequate fluid intake -Treat infections promptly -Regular labs- CBC, CMP -Have regular eye exams -Stroke screening tests -Complications: avascular necrosis, gallstones, nocturnal enuresis- bedwetting, priapism, and sickle cell retinopathy -Avoid cold water swimming -Take hydroxyurea and folic acid regularly -Pain management for home- ibuprofen, diclofenac, or heating pad -Infection prevention: hand washing, avoiding crowds, vaccines, and avoid raw food
Breast Cancer Patient Education
-Avoid wearing constrictive clothing on affected side -Keep affect arm elevated -Call health care provider if signs of inflammation occur -Wear medic-alert bracelet stating lymphedema arm -Protect affected arm and hand at all times from trauma, cuts, and bruises -Avoid use of affected arm for first few months
SLE Labs
-CBC, WBC- low -ESR, CRP, BUN, Cr- high (Cr 0.7-1.2) (BUN 8-20) (ESR 0-15)
Hypersensitivity Patient Education
-Encourage patient to reduce exposure to triggers -Carry an epi-pen for possible anaphylaxis -When a reaction occurs go to the hospital for evaluation (biphasic-steroids) -Inform providers about the allergy -Wear a medical alert bracelet -Identify risk factors for latex
Hemophilia Tx
-Factor VIII and factor IX -RICE
Skin Cancer Risk Factors
-Fair skinned -Light eyes -Red/Blonde hair -Chronic sun exposure -Family Hx -Location -Use tanning beds -Have many moles or irregular shaped moles -Get easily sun burnt or hx of sun burns
Lung Cancer Risk Factors
-Smoking -Carcinogens exposure: pollution, radiation/radon, asbestos, and industrial agents -Exposure to second hand smoke -Family Hx of lung cancer
HIV/AIDS Labs
-T-Cell count below 200 indicates full blown AIDS (T-cell 500-1200) -WBC count normal to decreased -Lymphopenia <30% of the normal number of WBCs (lymphocytes 1000-4800) -Thrombocytopenia decreased platelet count - risk for bleeding! (PLT 150-450) -AST and ASL will be elevated- liver
Which recommendation would the nurse emphasize during discharge planning for a child after a sickle cell vasoocclusive crisis?
An increased intake of fluids
A patient with chronic acquired immunodeficiency syndrome (AIDS) is taking antiretroviral therapy (ART) as well as medication for tuberculosis. Which laboratory data changes would the nurse anticipate?
Neutropenia Abnormal liver function tests
Which manifestation would the nurse include when the parents of a child who has just been diagnosed with hemophilia A ask what symptoms of bleeding should they look for in the future?
Nosebleeds Blood in the urine Painful and swollen joints Easy bruising Dark-colored tarry stools
After discussing percutaneous lung biopsy with the health care provider, a client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which action by the nurse is best?
Notify the health care provider that clarification is needed.
Which finding will the nurse expect during the assessment when a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital?
Left upper quadrant tenderness
At Risk for Latex Allergy
Healthcare workers Rubber industry Multiple surgeries Spina Bifida People who wear gloves frequently
HIV Risk Factors
High risk sexual behavior IV drug users Persons receiving blood products Healthcare workers Babies born to infected persons
A child with sickle cell anemia is admitted to the pediatric unit in a vasoocclusive crisis. Which interventions would be implemented after the pain is under control?
Rehydration Oxygen (O 2 ) therapy
Stage III
Spread further into nearby tissue
Which intervention would the nurse include when teaching a client about self-care after mastectomy to prevent infection and lymphedema?
Wear gloves when gardening. Apply a compression sleeve if edema occurs. Consider learning exercises for manual lymph drainage. Avoid blood draws in the arm on the side of the mastectomy.
Which action would the nurse anticipate when admitting a client having a sickle cell crisis to the nursing unit?
Administer hydroxyurea Apply oxygen via nasal cannula Administer intravenous (IV) hydration
A 4-year-old child diagnosed with sickle cell anemia is at a high risk of acquiring pneumococcal diseases. The child has previously received two doses of the pneumococcal conjugate vaccine (PCV). Based on the immunization protocol, which dose of PCV should the nurse administer?
Administer two more doses of PCV
Which purpose statements would the nurse use to fully explain antiretroviral therapy (ART) recently prescribed for a patient with human immunodeficiency virus (HIV)?
ART will decrease the viral load in the blood. The medications prevent transmission of the HIV disease. Prescribed medications maintain or increase the CD4 cell counts. Therapy includes prevention of HIV-related opportunistic infections.
A client is scheduled for a modified radical mastectomy. Which nursing intervention is most important in the client's preoperative plan of care?
Allowing her to express her feelings about surgery
Which action would the nurse take first after a client has a bone marrow aspiration performed?
Apply firm pressure over the aspiration site.
Nursing Interventions for Latex Allergy
Ask patient of any known latex allergies ID risk factors Use non latex supplies Keep latex free supply cart near patient room Apply cloth barrier when using BP cuff Use latex free syringes and meds MedAlert bracelet Inform HCP and paramedics Carry epi
Which intervention will be beneficial for the safe and effective care of a hospitalized immunosuppressed client?
Avoid using supplies from common areas. Encourage activity at an appropriate level. Use alcohol-based hand rubs before touching the client.
Which blood component will the nurse check for an increase in when monitoring effectiveness of filgrastim in a client who is immunosuppressed?
White blood cells
Risk Factors for Allergies
Hx of allergies Hx of asthma Family Hx of allergies
TNM Staging
T- tumor size, location, and degree of invasion N- regional lymph node invasion M- presence/absence of metastases
What are foods to avoid with a latex allergy?
Kiwi Banana Pineapple Tropical fruit Grapes Avocado Potato's
Which statement by an adolescent about sickle cell anemia would cause the nurse to conclude that the teaching has been understood?
"I'll start to have symptoms when I drink less fluid."
Which statement by an adolescent with hemophilia indicates a need for further teaching?
"I'll use a straight razor when I start shaving."
Which client statement indicates a risk of breast cancer?
"My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I consume two to four glasses of alcohol a day."
On the first day after a mastectomy, the nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. How would the nurse respond to the client's question as to why she needs to do these exercises?
"They will help stimulate peripheral circulation."
What are the 3 things to think about with Sickle Cell Anemia?
Oxygenation Pain Hydration
Which factor in the history of a client who is a farmer with a large crusty patch of skin on the cheek that still bleeds easily and has not gotten better despite using different remedies, would cause the nurse to suspect skin cancer?
Exposure to radiation
Which action will the nurse take to prevent the toxic effects of cisplatin when caring for a client with metastatic cancer?
Increase hydration to promote diuresis. *Cisplatin is nephrotoxic and can cause kidney damage unless the client is adequately hydrated*
Which method would the nurse use to measure the temperature of a 4- year-old child with leukemia who has mucositis?
Infrared, tympanic Temporal artery
Which characteristic does the nurse associate with a punch biopsy?
It is performed using a circular cutting instrument 2 to 6 mm in diameter.
The nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes would the nurse expect the parents to report?
Pale skin Eating less food Purplish spots on the skin
Which instructions would the nurse include when teaching preexposure prophylaxis (PrEP) to a group of adults at high risk of sexually acquired human immunodeficiency virus (HIV) infection?
Safe sex practices Regular HIV testing Risk reduction counseling
